This is a complex issue your raise, Jessica.

Tongue-tie is often undertreated, so it's not unusual for babies to need 
a second treatment if there was a submucosal component to the tie that 
was not identified during the first treatment. Also, Dr. Coryllos says 
that sometimes the soft tissue needs to retract a little after the first 
snip, before the rest of the frenulum becomes obvious. For this reason, 
she sometimes has to re-treat a child who is not completely better after 
one clipping.

Also, it's not always possible to restore the relationships between 
tongue, lower jaw, and airway that would have been if the child had not 
been tongue-tied. See Mukai's articles (Ankyloglossia with deviation of 
the epiglottis and larynx.) I think some of his stuff is available online.

That said, there is also the tendency to jump on the most obvious issue 
and not look at the totality of the child. Tongue-tie is classified as a 
minor anomaly. It is also a midline anomaly. Sometimes (not the majority 
of the time, but a significant minority) there are other midline defects 
such as ventricular septal defects (holes in the heart), hypospadias 
(misplacement of the exit of the urethra in boys), imperforate anus, or 
laryngomalacia/tracheomalcia. These things can have a synergistic effect 
on the baby's inability to feed.

There are maternal factors as well. A tongue-tied baby has a lot easier 
time with a mother with elastic breasts, everted nipples, and lots of 
milk making tissue, and a harder time with flat or inverted nipples.

So, we need to remember to look at the totally of the dyad, and try to 
rank the challenges in order of which is most problematic, and try to 
facilitate normal function in both partners, and compensate for what 
can't be changed.

Catherine Watson Genna, IBCLC  NYC

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